The Journal of Emergency Medicine

Early Goal-directed Therapy (EGDT) for Severe Sepsis/Septic Shock: Which Components of Treatment are More Difficult to Implement in a Community-based Emergency Department?

Rory O’Neill, Javier Morales, Michael Jule — 2011-05-06

Abstract: Background: Early goal-directed therapy (EGDT) has been shown to reduce mortality in patients with severe sepsis/septic shock, however, implementation of this protocol in the emergency department (ED) is sometimes difficult.Objectives: We evaluated our sepsis protocol to determine which EGDT elements were more difficult to implement in our community-based ED.Methods: This was a non-concurrent cohort study of adult patients entered into a sepsis protocol at a single community hospital from July 2008 to March 2009. Charts were reviewed for the following process measures: a predefined crystalloid bolus, antibiotic administration, central venous catheter insertion, central venous pressure measurement, arterial line insertion, vasopressor utilization, central venous oxygen saturation measurement, and use of a standardized order set. We also compared the individual component adherence with survival to hospital discharge.Results: A total of 98 patients presented over a 9-month period. Measures with the highest adherence were vasopressor administration (79%; 95% confidence interval [CI] 69–89%) and antibiotic use (78%; 95% CI 68–85%). Measures with the lowest adherence included arterial line placement (42%; 95% CI 32–52%), central venous pressure measurement (27%; 95% CI 18–36%), and central venous oxygen saturation measurement (15%; 95% CI 7–23%). Fifty-seven patients survived to hospital discharge (Mortality: 33%). The only element of EDGT to demonstrate a statistical significance in patients surviving to hospital discharge was the crystalloid bolus (79% vs. 46%) (respiratory rate [RR] = 1.76, 95% CI 1.11–2.58).Conclusion: In our community hospital, arterial line placement, central venous pressure measurement, and central venous oxygen saturation measurement were the most difficult elements of EGDT to implement. Patients who survived to hospital discharge were more likely to receive the crystalloid bolus.

TRIAD III: Nationwide Assessment of Living Wills and Do Not Resuscitate Orders

2011-11-21

Abstract: Background: Concern exists that living wills are misinterpreted and may result in compromised patient safety.Objective: To determine whether adding code status to a living will improves understanding and treatment decisions.Methods: An Internet survey was conducted of General Surgery, and Family, Internal, and Emergency Medicine residencies between May and December 2009. The survey posed a fictitious living will with and without additional clarification in the form of code status. An emergent patient care scenario was then presented that included medical history and signs/symptoms. Respondents were asked to assign a code status and choose appropriate intervention. Questions were formatted as dichotomous responses. Correct response rate was based on legal statute. Significance of changes in response due to the addition of either clinical context (past medical history/signs/symptoms) or code status was assessed by contingency table analysis.Results: Seven hundred sixty-eight faculty and residents at accredited training centers in 34 states responded. At baseline, 22% denoted “full code” as the code status for a typical living will, and 36% equated “full care” with a code status DNR. Adding clinical context improved correct responses by 21%. Specifying code status further improved correct interpretation by 28% to 34%. Treatment decisions were either improved 12–17% by adding code status (“Full Code,” “Hospice Care”) or worsened 22% (“DNR”).Conclusion: Misunderstanding of advance directives is a nationwide problem. Addition of code status may help to resolve the problem. Further research is required to ensure safety, understanding, and appropriate care to patients.

Use of RIFLE Criteria to Predict the Severity and Prognosis of Acute Kidney Injury in Emergency Department Patients with Rhabdomyolysis

Kathleen A. Delaney, Melissa L. Givens, Rais B. Vohra — 2011-05-06

Abstract: Background: RIFLE criteria (Risk, Injury, Failure, Loss, End-stage) have not been evaluated in Emergency Department (ED) patients at risk of acute kidney injury (AKI). AKI occurs in rhabdomyolysis.Study Objectives: To use RIFLE criteria to stratify the severity of AKI and predict prognosis in ED patients with acute rhabdomyolysis.Methods: This is a retrospective study of consecutive patients with rhabdomyolysis over a 44-month period. Data included ED admission anion gap, blood urea nitrogen (BUN), calcium, phosphate, potassium, urinalysis, toxicology screen, and hematocrit. Creatine kinase, creatinines, and hematocrits were followed serially. Hospital length of stay (LOS) and need for dialysis were also recorded.Results: RIFLE categories were calculated for 135 patients. At admission, 60 (44%) had no AKI, 20 (15%) had Risk, 32 (24%) had Injury, and 23 (17%) had Failure. These categories were significantly associated with increasing magnitude of volume depletion, potassium, phosphate, BUN, and the anion gap. They predicted differences in LOS, dialysis, discharge creatinine, and the rate of normalization of the admission creatinine. Mortality was low (2%), as was morbidity. Only 8/132 surviving patients (6%) were discharged with a creatinine >2 mg/dL.Conclusions: The RIFLE categories correlated significantly with known markers of rhabdomyolysis and AKI. They also predicted LOS, dialysis, renal morbidity, and the timing of recovery. RIFLE criteria could be used to predict the outcome of ED patients and facilitate admission and discharge decisions.

Intestinal Perforation Secondary to Blunt Inguinal Trauma in a Soccer Player: A Case Report

2009-05-22

Abstract: Background: Intestinal perforation caused by blunt trauma to an inguinal hernia is a very uncommon event. Case Report: We present the case of a 55-year old man who suffered trauma to the inguinal area while playing soccer and later developed intense abdominal pain with no categorical signs of peritoneal irritation. Computed tomography scan at arrival showed a right inguinal hernia, with partial protrusion of the ileum, inflammatory changes of the mesenteric fat tissue inside the hernial sac, and free intraperitoneal fluid. Several hours later he developed hypotension and fever. An emergency laparotomy was performed, revealing ileum perforation with peritonitis. Intestinal perforation was repaired without intestinal resection. After surgery, the patient developed severe septic shock with multiple organ failure. He recovered without sequelae and was discharged 3 weeks later. Conclusion: This case emphasizes the potential clinical complications associated with this condition.

Charles Bonnet Syndrome: Three Cases in the Emergency Department

Elizabeth J. Frost, J. Lawrence Mottley, Jonathan A. Edlow — 2009-05-01

Abstract: Background: Charles Bonnet Syndrome (CBS) is a cause of visual hallucinations in elderly patients that is often unrecognized by emergency physicians and has a relatively benign course. As the population ages, it is likely that the number of cases of CBS will increase (and thus, the numbers of those who present to an Emergency Department [ED] will be increasing). Objectives: The case reports presented in this article will facilitate the recognition of CBS by the emergency physician. Case Report: We describe 3 patients who presented to one ED for visual disturbances and were diagnosed with CBS in a 4-month time period. Conclusion: Recognition of this unusual but stereotypical cause of visual disturbances facilitates an accurate diagnosis, and spares patients the time and expense of blood testing, imaging, and consultations. If emergency physicians begin to recognize this benign entity, we can provide improved (and safer) patient care with appropriate ED interventions.

Bronchial Rupture by an Unusual Mechanism of Thoracic Hyperextension

Xavier Soler, Rebecca Sell, José Maestre, Juan Ruiz-Manzano — 2009-05-01

Abstract: Background: Tracheobronchial disruption usually occurs in the setting of blunt chest trauma and may be overlooked due to co-existing injuries and non-specific symptoms. Objectives: Review the mechanism, diagnosis, and therapeutic management of tracheobronchial disruption. Case Report: We present a case of a young woman with a bronchial rupture 3 weeks after accidental strangulation. Initial diagnosis was delayed due to the unusual presentation. She presented with acute respiratory failure and hemodynamic collapse after slowly progressive shortness of breath with exertion. Conclusions: This case report provides an overview of the clinical features of bronchial disruption by highlighting the varying degrees of clinical presentation and management. Urgent bronchoscopy is indicated for diagnosis, and surgical intervention for treatment.

Torsion of an Undescended Testis Located in the Inguinal Canal

Andrew P. Weiss, Jon Van Heukelom — 2011-09-09

Abstract: Background: Torsion of undescended testis located within the inguinal canal is a rare finding in the emergency department (ED). This diagnosis can present as undifferentiated abdominal or groin pain, and a full genitourinary examination is essential to making this diagnosis.Objectives: We present this case to increase awareness among emergency physicians regarding torsion of undescended testis.Case Report: A 5-year-old boy presented to the ED with abdominal pain and a mass in his right groin. Physical examination and Doppler ultrasound were used to diagnose torsion of undescended testis.Conclusions: In a patient with undescended testis, torsion must be considered as a cause of abdominal or groin pain. Full genitourinary examination is essential to making this diagnosis.

Pneumoperitoneum after Sexual Assault in a Patient Who Had Hysterectomy 30 Years Ago: Case Report

Daniel D. Im, Peter S. Pak, Bennett Cua, Elyssa Feinberg — 2011-08-19

Abstract: Background: A non-surgical etiology accounts for approximately 10% of cases of pneumoperitoneum. However, in the patient with pneumoperitoneum, one must be suspicious of the less common non-surgical etiologies, including coitus, to avoid unnecessary laparotomy.Objectives: To report a case of pneumoperitoneum caused by coitus during sexual assault in a patient who had a hysterectomy 30 years ago.Case Report: The authors present a case of non-surgical pneumoperitoneum after sexual assault occurring over 30 years after abdominal hysterectomy.Conclusion: This case is an important reminder that a thorough sexual and gynecologic/obstetrical history is an essential tool in identifying the patient who does not require laparotomy.

Recurrent Respiratory Depression Associated with Fentanyl Transdermal Patch Gel Reservoir Ingestion

Joseph L. D’Orazio, Jason A. Fischel — 2011-04-29

Abstract: Background: Opioid abuse is common in the United States and is currently on the rise. Fentanyl transdermal patches (FTPs) have been on the market since 1991, and have recently become a popular source of opioids for abusers. There are currently two distinct FTP designs available on the market today; a gel reservoir system and a matrix construct. The gel reservoirs of FTPs contain massive amounts of fentanyl and are easily extractable for abuse. Ingesting the gel reservoir of an FTP is potentially lethal.Case Series: In this case series, 4 patients ingested the gel reservoir of an FTP and experienced severe and recurrent respiratory depression necessitating continuous naloxone infusions. All patients responded adequately to initial prehospital doses of naloxone (0.8–2 mg intravenous) but developed recurrent respiratory depression within 2 h of presentation to the hospital.Conclusion: The gel reservoir of an FTP contains massive amounts of fentanyl. Ingestion of the gel may cause severe and recurrent respiratory depression necessitating repeated naloxone boluses, continuous naloxone infusion, and a prolonged observation period.

Whole Fentanyl Patch Ingestion: A Multi-center Case Series

2011-06-17

Abstract: Background: Fentanyl is a potent synthetic opioid with large abuse potential. A common preparation of fentanyl is a sustained-release transdermal patch. To our knowledge, there are only two published case reports of whole patch ingestion. A case series of 76 patients with a history of whole patch ingestion is reported.Study Objectives: To characterize whole fentanyl patch ingestion to develop a clinical guideline for management.Methods: This was a retrospective review of all patients who ingested intact fentanyl patches as reported to three regional poison information centers (RPIC) from 2000 to 2008. The three RPIC medical record databases were queried for all exposures with a substance code matching the Micromedex® (Thomson Reuters, New York, NY) fentanyl product codes. Collected data included: age, gender, reason for the exposure, number of patches ingested, dose (μg/h), symptoms, symptom onset and duration, treatment hospital flow (level of care), and outcome.Results: A total of 76 patients met the inclusion criteria. Two patients had both time of onset and symptom duration documented. In both patients, the signs and symptoms developed within 2 h of the exposure, and the patients were asymptomatic at 6½ and 9 h, respectively. Fifty-eight (78.3%) patients were admitted. Of those patients who were admitted, 56 (96.5%) were admitted to a critical care unit. Fourteen patients required intubation, and naloxone infusions were documented in eight cases.Conclusion: Ingestion of whole fentanyl patches may lead to prolonged and significant toxicity based on these poison center data.

Prehospital Use of Continuous Positive Airway Pressure for Acute Severe Congestive Heart Failure

Joe E. Dib, Scott A. Matin, Amy Luckert — 2011-09-12

Abstract: Background: The utility of continuous positive airway pressure (CPAP) in the in-hospital treatment of congestive heart failure (CHF) is well established. Its exact role is less clear in the prehospital arena.Objective: To describe the prehospital use of CPAP for patients presenting with acute severe heart failure in a large Emergency Medical Services system in New Jersey.Methods: Retrospective review of prehospital charts from January 1, 2005 to December 31, 2006 of patients treated for acute CHF. Inclusion criteria for eligibility for CPAP mask use were: respiratory rate > 25 breaths/min, labored and shallow breathing, bilateral rales, history of CHF, intact mental status, and prehospital clinical diagnosis of CHF. Data collected included demographics, vital signs, oxygen saturation (SaO2), need for endotracheal intubation (ETI), and complications.Results: There were 1306 charts reviewed; 387 patients met inclusion criteria. Of the 387, 149 patients had placement of CPAP (38.5%). The prehospital treatment times were (CPAP = 30 min; non-CPAP = 31 min; p < 0.01). The increase in SaO2 for the CPAP group (9%) vs. the non-CPAP group (5%) was statistically significant (p < 0.01). Systolic blood pressure (BP) reduction (CPAP [27.1 mm Hg], non-CPAP [19.9 mm Hg], p < 0.01), diastolic BP reduction (CPAP [14.1 mm Hg], non-CPAP [7.4 mm Hg], p < 0.01), heart rate reduction (CPAP [17.2 beats/min], non-CPAP [9.6 beats/min], p < 0.01), respiratory rate reduction (CPAP [5.63], non-CPAP [4.09], p < 0.01), and ETI reduction (CPAP [2.6%], non-CPAP [5.46%], p < 0.01), all were statistically significant. Adjunctive CHF treatments were similar between the groups.Conclusion: The use of CPAP for eligible patients with acute severe CHF seems to be feasible and beneficial. Large-scale randomized prospective prehospital studies are needed to validate these results.

Comparative Sensitivity of Computed Tomography vs. Magnetic Resonance Imaging for Detecting Acute Posterior Fossa Infarct

David Y. Hwang, Gisele S. Silva, Karen L. Furie, David M. Greer — 2012-02-06

Abstract: Background: Posterior fossa strokes, particularly those related to basilar occlusion, pose a high risk for progression and poor neurological outcomes. The clinical history and examination are often not adequately sensitive or specific for detection.Study Objectives: Because this population stands to benefit from acute interventions such as intravenous and intra-arterial tissue plasminogen activator, mechanical thrombectomy, and intensive monitoring for neurologic deterioration, this study examined the sensitivity of non-contrast head computed tomography (NCCT) for diagnosing posterior fossa strokes in the emergency department.Methods: This study analyzed a prospectively collected database of acute ischemic stroke patients who underwent head NCCT within 30h of symptom onset and who were subsequently found to have a posterior fossa infarct on brain magnetic resonance imaging (MRI) performed within 6h of the NCCT.Results: There were 67 patients identified who had restricted diffusion on MRI in the posterior fossa. The National Institutes of Health Stroke Scale (NIHSS) scores ranged from 0 to 36, median 3. Only 28 patients had evidence of infarction on the initial NCCT scan. The timing of NCCT scans ranged from 1.2 to 28.9h after symptom onset. The sensitivity of NCCT was 41.8% (95% confidence interval 30.1–54.4). The longest period of time between symptom onset and a negative NCCT with a subsequent positive diffusion-weighted imaging MRI was 26.7h.Conclusions: Head NCCT imaging is frequently insensitive for detecting posterior fossa infarction. Temporal evolution of strokes in this distribution, coupled with beam-hardening artifact, may contribute to this limitation. When a posterior fossa stroke is suspected and the NCCT is non-diagnostic, MRI is the preferred imaging modality to exclude posterior fossa infarction.

Identification of Intraluminal Thrombus by Ultrasonography in Emergency Department Patients with Acute Deep Venous Thrombosis

Ninfa Mehta, Joshua Schecter, Michael Stone — 2011-10-24

Abstract: Background: Traditionally, the diagnosis of deep venous thrombosis (DVT) using duplex ultrasonography (DU) has relied on the absence of venous compressibility. Visualization of an intraluminal thrombus is considered an uncommon finding.Objectives: The purpose of this study is to determine the frequency of intraluminal thrombus in emergency department (ED) patients diagnosed with acute DVT.Methods: Retrospective chart review of adult ED patients with DU examinations demonstrating acute DVT. Patients with chronic DVT or patients in whom DU did not demonstrate DVT were excluded from data analysis. Study reports and ultrasound images were reviewed and analyzed for the presence of intraluminal thrombus.Results: There were 189 patients who met inclusion criteria, of which 160 (85%) were found to have intraluminal thrombus.Conclusion: Intraluminal thrombi are present in the majority of patients in our ED in whom acute DVT is identified by DU.

Sacral Decubitus Ulcers and Bacterial Meningitis

2012-02-27

Dr. Leah Honigman: Today’s case is that of an 86-year-old woman with a history of dementia who presented to the Emergency Department (ED) with fever and altered mental status. On the day of presentation, the patient’s husband found her slumped in a chair. He noted her to have decreased responsiveness and lethargy over the previous 6 h and subsequently brought her in for evaluation. The patient’s husband was the primary historian, given her confusion. He also stated that she had been complaining of some abdominal pain but denied recent nausea or vomiting.

Disseminated Lemierre Syndrome Presenting as Septic Arthritis

Bryan J. Chow, Janis P. Tupesis — 2010-11-01

A 26-year-old man was brought to our institution with left elbow pain. He had presented to the Emergency Department (ED) 1 week earlier with fever, sore throat, and cough. He was diagnosed with pneumonia () and was discharged home with azithromycin. Five days before presentation, he saw his primary care physician (PCP) for worsening shortness of breath and hemoptysis. Ciprofloxacin and prednisone were added to the regimen and a purified protein derivative (PPD; tuberculin) test was placed. Three days before presentation, the patient had another visit with his PCP, at which time the PPD test was negative, the patient's shortness of breath had resolved, but his upper respiratory symptoms persisted.

Multiple Occipital Ring-Enhancing Lesions in a Healthy Woman

Sapna Pawa, Jarone Lee, Kaushal H. Shah — 2010-06-07

A 41-year-old woman from Haiti with no past medical or surgical history presented to the Emergency Department with low-grade diffuse headaches for 3 weeks. She described her headache as constant, mild, non-radiating, and difficult to localize. She had never had headaches before. The headache did not interfere with her daily activities. She also reported occasional blurred vision and difficulty reading. She denied fevers, chills, weight loss, nausea, vomiting, and numbness or weakness in the extremities. Her physical examination showed 20/20 bilateral vision and left upper quadrantanopia. The rest of her neurological and physical examination was unremarkable. Her laboratory studies were unremarkable; her white blood cell count was within normal range without neutrophilia or eosinophilia. A non-contrast computed tomography scan of her head () and subsequent magnetic resonance imaging (MRI) studies of her brain (, ) are shown below.

Charles McBurney: McBurney's Point

Casey A. Grover, George Sternbach — 2011-10-07

Abstract: Charles McBurney published a treatise on appendicitis in 1891, in which he described the exact point on the abdomen at which tenderness was maximal in cases of acute appendicitis—the point now known as “McBurney’s point.” He also described his approach to both the diagnosis and management of appendicitis, which at the time consisted of careful observation, total disuse of the stomach, and early laparotomy. Since 1891, many advances in the diagnosis of acute appendicitis have been made. Emergency physicians evaluating patients with abdominal pain may rely on laboratory studies, particularly the white blood cell count, and abdominal imaging with either ultrasound or computed tomography in addition to the history and physical examination. Despite these advances, tenderness to palpation over McBurney’s point remains a key finding on abdominal examination in the assessment of patients with abdominal pain.

A Physician's Got to Know His (Test's) Limitations

Jonathan Edlow — 2012-02-03

“A man’s got to know his limitations.” So ends the 1973 Dirty Harry movie, “Magnum Force.” The same is true of physicians; we have to know our limitations and we also have to know the limitations of our diagnostic tests. Although it is commonly stated that non-contrast brain computed tomography (CT) scan is insensitive to acute posterior circulation infarction, this has not been well studied. In this issue of The Journal of Emergency Medicine, Hwang et al. present data on 67 patients with acute posterior fossa infarction, who first had CT followed by diffusion-weighted magnetic resonance imaging (MRI) within 6h, that revealed an acute ischemic stroke (see Hwang article in this issue).

Lamotrigine-associated Thrombocytopenia and Leukopenia

Mesut Okur, Avni Kaya, Hüseyin Çaksen, Gökmen Taşkın — 2010-07-26

To the Editor: Lamotrigine (LTG), a wide-spectrum antiepileptic drug, is derived from the dihydrofolate reductase inhibitor class of compounds and is thought to act mainly through blocking the influx of sodium ions, thereby reducing excess glutamate release and stabilizing neuronal membranes . It is effective as an adjunctive treatment of refractory partial seizures and idiopathic generalized epilepsy in adults and children . Rash has been reported as the most frequent side effect of LTG, whereas blood dyscrasias have been noted rarely . We report a boy who developed thrombocytopenia and leukopenia after receiving LTG for epilepsy.

Subcapsular Hepatic Hematoma Revealed by Hemorrhagic Shock in a Preeclamptic Patient

S. Zidouh, L. Belyamani, J. Kouach, N. Drissi Kamili — 2010-09-28

To the Editor: Described for the first time in 1884, subcapsular hepatic hematoma is an exceptional complication of eclampsia. Hemorrhagic shock revealing a subcapsular hepatic hematoma in a full-term pregnancy occurs rarely, in approximately 1% .

Takotsubo Cardiomyopathy Associated with Acute Subarachnoid Hemorrhage

2010-10-08

To the Editor: Takotsubo cardiomyopathy is a myocardial disorder characterized by acute myocardial infarction-like electrocardiographic changes and transient left ventricular apical ballooning . Subarachnoid hemorrhage is known to be associated with this syndrome, related in part to an elevation in levels of circulating catecholamines .

Gender Disparity in Emergency Department Non-ST Elevation Myocardial Infarction Management

2010-10-01

Abstract: Background: Many studies have looked at differences between men and women with acute coronary syndrome. These studies demonstrate that women have worse outcomes, receive fewer invasive interventions, and experience delay in the initiation of established medical therapies.Objective: Using innovative technology, we set out to unveil and resolve any gender disparities in the evaluation and treatment of patients presenting with a positive troponin while in the emergency department. Our goal was to assess the feasibility of using a business management query system to create an automated data report that could identify deficiencies in standards of care and be used to improve the quality of treatment we provide our patients.Methods: Over a 12-month period, key markers for patients with non-ST elevation myocardial infarction (NSTEMI) were tracked (e.g., time to electrocardiogram, door to medications). During this time, educational endeavors were initiated utilizing McKesson’s Horizon Business Insight™ (McKesson Information Solutions, Alpharetta, GA) to illustrate gender differences in standard therapy. Subsequently, indicators were evaluated for improvement.Results: Substantial improvements in key indicators for management of NSTEMI were obtained and gender differences minimized where education was provided.Conclusion: The integration of these information systems allowed us to create a successful performance improvement tool and, as an added benefit, nearly eliminated the need for manual retrospective chart reviews.

American Academy of Emergency Medicine

2012-05-01

Inter-rater Reliability of Sonographic Measurements of the Inferior Vena Cava

2012-01-13

Abstract: Background: Bedside ultrasound is emerging as a useful tool in the assessment of intravascular volume status by examining measurements of the inferior vena cava (IVC). Many previous studies do not fully describe their scanning protocol.Objectives: The objective of this study was to evaluate which of three commonly reported IVC scanning methods demonstrates the best inter-rater reliability.Methods: Three physicians visualized the IVC in three common views and utilized M-mode to measure the maximal and minimal diameter during quiet respiration. Pairwise correlation coefficients were determined using Pearson product-moment correlation.Results: The most reliable pair of measurements (inspiratory and expiratory) was found to be using the anterior midaxillary line longitudinal view with a Kappa value for both at 0.692.Conclusion: Imaging with the anterior midaxillary longitudinal approach using the liver as an acoustic window provides the best inter-rater reliability when measuring the IVC. Our findings demonstrate that IVC measurements differ based on anatomic location.

Cricoid Pressure Provides Incomplete Esophageal Occlusion Associated with Lateral Deviation: A Magnetic Resonance Imaging Study

2011-06-13

Abstract: Background: Cricoid pressure is a routine component of rapid sequence induction and is designed to reduce the risk of reflux and its associated morbidity. Recent studies have raised questions regarding the efficacy of cricoid pressure in terms of changes in the pharyngeal and esophageal anatomy.Objective: This current descriptive study was designed to observe the anatomical effect of cricoid pressure on the occlusion of esophageal lumen in conscious volunteers using magnetic resonance imaging (MRI).Methods: We quantitatively assessed esophageal patency before and during application of cricoid pressure in 20 awake volunteers utilizing MRI.Results: Target cricoid pressure was achieved in 16 of 20 individuals, corresponding to a mean percentage reduction in cricovertebral distance of 43% (range 25–80%). Cricoid pressure was applied incorrectly in 4 (20%) individuals as evidenced by no change in the cricovertebral distance. Incomplete esophageal occlusion was seen in 10 of 16, or 62.5% (95% confidence interval 35–85%) of individuals when appropriate cricoid pressure was applied. Incomplete esophageal occlusion was always associated with a lateral deviation of the esophagus. None of the 6 subjects with complete occlusion had esophageal deviation during the appropriate application of cricoid pressure.Conclusion: Effective application of cricoid pressure by an experienced operator frequently resulted in lateral deviation of the esophagus and incomplete occlusion of esophageal lumen. Reliance on cricoid pressure for esophageal occlusion requires further evaluation utilizing functional studies.

The Use of Cephalosporins in Penicillin-allergic Patients: A Literature Review

James D. Campagna, Michael C. Bond, Esteban Schabelman, Bryan D. Hayes — 2011-07-11

Abstract: Background: The practice of avoiding cephalosporin administration to penicillin-allergic patients persists despite the low rate of cross reactions between both groups of antibiotics.Objective: The purpose of this literature review is to evaluate the published evidence regarding the commonly held belief that patients with a history of an allergic reaction to penicillin have a significantly increased risk of an allergic reaction to cephalosporins.Materials and Methods: Articles were identified through a computerized search of MEDLINE from 1950 to the present using the search terms “penicillin$,” “cephalosporin$,” “allerg$,” “hypersensitivity,” and “cross-react$.” All articles were reviewed, and additional sources cited in them were added to the literature review.Results: Penicillins have a cross allergy with first-generation cephalosporins (odds ratio 4.8; confidence interval 3.7–6.2) and a negligible cross allergy with second-generation cephalosporins (odds ratio 1.1; confidence interval 0.6–2.1). Laboratory and cohort studies confirm that the R1 side chain is responsible for this cross reactivity. Overall cross reactivity between penicillins and cephalosporins is lower than previously reported, though there is a strong association between amoxicillin and ampicillin with first- and second-generation cephalosporins that share a similar R1 side chain.Conclusions: Although a myth persists that approximately 10% of patients with a history of penicillin allergy will have an allergic reaction if given a cephalosporin, the overall cross-reactivity rate is approximately 1% when using first-generation cephalosporins or cephalosporins with similar R1 side chains. However, a single study reported the prevalence of cross reactivity with cefadroxil as high as 27%. For penicillin-allergic patients, the use of third- or fourth-generation cephalosporins or cephalosporins with dissimilar side chains than the offending penicillin carries a negligible risk of cross allergy.

Challenging and Emerging Conditions in Emergency Medicine

Edward J. Otten — 2012-03-02

Emergency medicine textbooks are generally divided into two types: the general, which attempts to cover all of emergency medicine, and the specific, which covers a particular area such as gastrointestinal emergencies or neurologic emergencies. Although many of these texts mention common problems, few cover in any detail the rare, unusual, or emerging problems that we commonly encounter. Recently I have seen patients status post-bariatric surgery, patients on human immunodeficiency virus (HIV) therapy, geriatric trauma patients, and patients on complex chemotherapeutic protocols. Patients have become more complex and are living longer with diseases such as sickle cell anemia and cystic fibrosis who formerly would not survive until adulthood. Post-resuscitation-induced hypothermia has been shown to be the most beneficial care we can offer, but many emergency physicians don’t initiate it. Dr. Venkat and his 27 contributors have selected a number of these conditions and have presented an approach to managing them. Nationally recognized emergency medicine experts such as Clifton Callaway, Andra Blomkalns, and Mary Ann J. Howland have authored chapters, and Dr. Venkat has recruited non-emergency medicine subject matter authorities for the specific areas covered.

Risk of Acute Myocardial Infarction after the Death of a Significant Person in One's Life: The Determinants of Myocardial Infarction Onset Study: Mostofsky E, Maclure M, Sherwood JB, et al. Circulation 2012;125:491–6.

Maegan S. Reynolds — 2012-05-01

In this retrospective cohort crossover analysis, the authors attempted to show that a recent death, independent of other variables, increased one's risk of having an acute myocardial infarction (MI). The study identified 1985 self-matched people between 1989 and 1994 who were clinically determined to have an MI. The authors found 270 patients (13.6%) reported the death of a significant person in their life within the 6 months before their MI. The rate of patients suffering MI was inversely correlated with time from death event, that is, an incidence rate ratio (IRR) of 21.1 within 24 h of death event, which decreased to 5.8 at the end of the first week. With the exposure of a death event, there was an additional MI per exposed individuals at an increasing rate based on initial risk, that is, one excess MI per 1394 low-risk individuals within 1 week, and one excess MI per 320 in high-risk individuals within 1 week of a death event. Additionally, the IRR was higher at 27.7 among patients who reported that the death was moderately or extremely meaningful, vs. an IRR of 21.1 for all exposed patients. Interestingly, the IRR was increased in those who had a recent death and were aged < 65 years, engaging in physical activity ≥ 3 times per week, and those with no history of coronary artery disease. The authors concluded that the overall risk of an MI was increased (especially within the first week) for all individuals, regardless of baseline risk, after the death of a significant person and while suffering from bereavement.

Lack of Neurologic Improvement after Aortic Repair for Acute Type A Aortic Dissection Complicated by Cerebral Malperfusion: Predictors and Association with Survival: Morimoto N, Okada K, Okita Y. J Thorac Cardiovasc Surg 2011;142:1540–4.

Lina Tran — 2012-05-01

This was a single-center retrospective study out of Japan that aimed to evaluate the predictors of a lack of neurologic improvement after aortic repair for acute Type A aortic dissection complicated by preoperative cerebral malperfusion. Of the 157 patients with acute Type A aortic dissection undergoing surgical repair, the study identified 41 patients with cerebral malperfusion syndrome, defined as a newly developed motor or sensory deficit with clinical evidence of decreased carotid arterial blood flow by ultrasound or computed tomographic angiography. Of the 41 patients in the study, 26 patients (63%, group I) had neurologic improvement and 15 patients (37%, group II) had a lack of neurologic improvement, defined as a no-more-than-3-point difference between baseline and postoperative National Institutes of Health Stroke Scale (NIHSS) score. The study found two statistically significant predictors of lack of neurologic improvement: baseline preoperative NIHSS (odds ratio [OR] 6.7; 95% confidence interval [CI] 1.4–32.4, p = 0.02) and time to surgery (OR 14.6; 95% CI 2.7–8.5, p = 0.002). Using receiver operating characteristic analysis, the optimal cutoffs were found to be baseline NIHSS of < 11 (sensitivity 80%, specificity 85%) and time to surgery > 9.1 h (sensitivity 67%, specificity 96%). The positive likelihood ratio of neurologic recovery was 3.8 when at least one of the risk factors was present. The researchers also attempted to assess the relationship between lack of neurologic improvement with short- and long-term survival and found overall 30-day mortality was 14.6%; 0% in Group I and 40% in Group II (p=0.009), where large hemispheric cerebral infarction accounted for all early deaths. Similarly, lack of neurologic improvement was significantly associated with poor 5-year survival: 33% 5-year survival in Group II, whereas Group I had 84% 5-year survival (p < 0.001 by log-rank test). The researchers concluded that baseline NIHSS and time to surgery were the greatest predictors of lack of neurologic improvement after aortic repair for acute Type A aortic dissection complicated by preoperative evidence of cerebral malperfusion, and that these predictors were associated with lower survival rates. Based on their findings, the researchers went on to conclude that the most important predictor of neurologic recovery was not actual time to surgery but rather, the time to relief of cerebral malperfusion.

Randomized Clinical Trial for Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo: Kim J, Oh S, Lee S, et al. Neurology 2012;78:159–66.

Elena Ewert — 2012-05-01

Dizziness is a common complaint in the emergency department, with benign paroxysmal positional vertigo (BPPV) being the underlying etiology in a number of cases. BPPV involving the horizontal semicircular canal (HC-BPPV) is a subtype of BPPV that accounts for 10–42.7% of BPPV cases. It is characterized by horizontal nystagmus and positional vertigo, and is divided into geotropic, where there is free-floating debris in the endolymph of the horizontal canal (canalolithiasis), and apogeotropic, where otolithic debris is attached to the anterior arm of the horizontal canal near the cupula (canalolithiasis) or attached to the cupula itself (cupulolithiasis). Clinically, these two are distinguished by laying the patient supine and turning his or her head to either side; geotropic HC-BPPV causes nystagmus to beat toward the undermost ear, whereas apogeotropic HC-BPPV causes nystagmus to beat toward the uppermost ear. The ear with the lesion can then be determined by further positional techniques that elicit nystagmus (for example, lying down and head bending). Therapy for apogeotropic HC-BPPV utilizes maneuvers meant to detach the otolith and move particles toward the posterior part of the horizontal canal. Head-shaking uses accelerating-decelerating forces to mechanically detach the otolith, whereas the Gufoni maneuver utilizes ipsilesional side-lying and upward head turn to move debris toward the vestibule. This study utilized a randomized, prospective, double-blind, sham-controlled approach to determine the immediate and long-term therapeutic benefit of Gufoni and head-shaking maneuvers in 157 consecutive patients aged 18 years or over with apogeotropic HC-BPPV from 10 dizziness clinics throughout Korea. Patients were excluded if they had examination findings concerning for central pathologies (such as limb ataxia, balance dysfunction, or central ocular motor signs). Diagnostic maneuvers were employed to ensure that findings of nystagmus were consistent with apogeotropic HC-BPPV. Outcomes were assessed within 1 h after a maximum of two trials of each maneuver, as well as the following day; four weekly follow-up visits after the initial maneuver assessed long-term benefit. Better responses were found with both the Gufoni (38/52, 73.1%) and head-shaking (33/53, 62.3%) maneuvers, compared to the sham maneuver (17/49, 34.7%). The Gufoni maneuver was more effective than the sham maneuver, with an odds ratio (OR) of 5.23 (95% confidence interval [CI] 2.19–12.47, p = 0.0001), absolute risk reduction (ARR) of 0.37, and number needed to treat (NNT) 2.66. Similarly, head-shaking compared to the sham maneuver had an OR = 3.16 (95% CI 1.34–7.47, p = 0.007), ARR = 0.25, and NNT = 3.97. Although both therapies were more beneficial than the sham maneuver, therapeutic effects were more immediately notable after the Gufoni maneuver (OR = 5.86, 95% CI 2.48–13.78, p < 0.001, ARR = 0.38, NNT = 2.60) compared to head-shaking (OR = 3.20, 95% CI 1.42–7.17, p = 0.004, ARR = 0.28, NNT = 3.54). Additionally, long-term benefits were more pronounced with the Gufoni maneuver (OR = 9.95, 95% CI 1.19–82.83, p = 0.014, ARR = 0.14, NNT = 6.94) than with head-shaking (OR = 1.87, 95% CI 0.56–6.17, p = 0.23, thus, not statistically significant). Cumulative therapeutic effects were similarly improved at 4 weeks, with both the Gufoni maneuver and head-shaking compared to the control (p < 0.001 and p = 0.026, respectively), and the differences between the two maneuvers were not significant (p = 0.239) according to Kaplan-Meier survival curve analysis. Nevertheless, 98% of patients (48/49) in the sham group had resolution of symptoms at the 1-month follow-up interval; overall improvement was 97.4% (150/154). Part of this may be due to the possible therapeutic effect of the sham maneuver itself, which consisted of lying on the unaffected side from a seated position and then sitting back up after 2 min. In summary, whereas HC-BPPV is commonly a self-limited disease, the Gufoni maneuver and head-shaking maneuver successfully decreased symptoms both at initial presentation and 1 month after intervention.

Multicenter Analysis of Quality Indicators for Children Treated in the Emergency Department for Asthma: Sills MR, Ginde AA, Clark S, Camargo CA. Pediatrics 2012;129:e325–32.

Maegan S. Reynolds — 2012-05-01

In this prospective multi-center cohort analysis, the authors retrospectively looked into the association between process and outcome measures in acute asthma care for children in the emergency department (ED). It has been well studied within the adult asthma population that guideline compliance is predictive of discharge from the ED without significant relapse. The authors looked at 1426 asthma patients aged 2–17 years in 14 EDs during the fall of 1997, spring of 1998, and fall of 2000. The seven processes measured were receipt of: 1) inhaled β-agonists, 2) inhaled anticholinergics, 3) systemic steroids, 4) prescription of oral corticosteroids at discharge, and 5) non-treatment with methylxanthines; additionally, receipt of: 6) β-agonist and 7) corticosteroid treatment within 1 h of ED arrival. The outcomes measured were discharge vs. admission, and relapse or ongoing symptoms as determined with a 2-week telephone follow-up interview. Overall, process measures were shown to have a concordance between 65% (receipt of inhaled anticholinergics) and 99% (receipt of inhaled β-agonist), with a total composite score for the five non-time-sensitive measures of 84%. Outcomes measures showed that 62% had successful discharge, 15% had relapse or ongoing symptoms after discharge, and 24% were admitted. From these findings, the authors determined secondarily that timely β-agonist administration increased the odds of admission by 4.4-fold, and the administration of systemic corticosteroid was also associated with higher admission rates – a result that authors felt was likely confounded by the severity of the patients' presentations. Overall, there was no clinically significant association between process measure and outcome measure in this cohort of children treated for acute asthma contrary to previous pediatric and adult studies.

Predictors of Cognitive Function and Recovery 10 Years after Traumatic Brain Injury in Young Children: Anderson V, Godfrey C, Rosenfeld JV, et al. Pediatrics 2012;129:254–61.

Lina Tran — 2012-05-01

Traumatic brain injury (TBI) is one of the leading causes of disrupted development in childhood. Previous studies have demonstrated that severe injury at a young age is associated with poorer outcomes at least 5 years post-injury. This was a prospective longitudinal study that compared recovery of cognitive and functional skills in 40 children with early childhood TBI to 10 years post-injury to healthy controls. The researchers recruited 40 children with TBI from their previously reported study and divided them into three groups based on injury severity: mild, moderate, or severe (as determined by Glasgow Coma Scale cutoffs or presence of neurologic deficit) and compared them to 16 healthy controls with respect to the following measures: cognition (using Wechsler Intelligence Scale for Children [WIS-IQ]), adaptive ability (using Adaptive Behavior Assessment System [ABAS-II]), executive function (using Behavior Rating Inventory of Executive Function [BRIEF]) and social skills (using Social Skills Rating System [SSRS]) at four times post-injury: 1 (0–3 months), 2 (12 months), 3 (30 months), and 4 (10 years). The study also attempted to identify predictors of recovery, including environmental factors: socioeconomic status (SES) and family functioning (using Family Functioning questionnaire [FFQ]) and pre-injury characteristics (using Vineland Adaptive Behavior scales [VABS]). The study showed significant difference in children with severe TBI vs. the control group in cognition as measured by WIS-Full Scale IQ (FSIQ), at time 1, F(3, 55) = 3.36, p = 0.03 and time 4, F(3, 55) = 4.63, p = 0.01. With respect to predictors of 10-year outcomes (time 4), pre-injury characteristics (VABS) was highly correlated with cognition (all IQ variables) as well as adaptive abilily (ABAS), β = 0.57, t = 2.52, p = 0.03. Family functioning (FFQ) was also significantly predictive of recovery of social skills (SSRS) at 10 years, β = 0.51, t = 2.15, p = 0.05. When plotting recovery trajectories, although children with severe TBI demonstrated the lowest mean scores at all time points on all IQ measures, there was no evidence of severity-related differences in recovery rate. Although the study confirmed findings from prior studies that severe TBI in early childhood is associated with persistent deficits, it suggests two new concepts: 1) there may be an “injury threshold” beneath which children may escape serious sequelae, and 2) the recovery trajectories plateau from 5 to 10 years for all groups, regardless of the injury severity, implying that although children with early severe TBI may never “catch up” to their peers, the gap does not widen during this period.

Emergency Department Adherence to American Heart Association Guidelines for Blood Pressure Management in Acute Ischemic Stroke: Grise E, Adeoye O, Lindsell C, et al. Stroke 2012;43:557–9.

Elena Ewert — 2012-05-01

Acute ischemic stroke (AIS) is commonly associated with elevated blood pressure (BP). Severely elevated BP levels are associated with poor outcomes and increased risk for neurological decline. For BP > 220/120 mm Hg, antihypertensive agents are recommended by the American Heart Association (AHA) to help improve mortality. However, every 10-mm Hg fall in systolic BP levels < 150 mm Hg is associated with 17.9% increased risk of death at 2 weeks, and as such, goal reductions are only 15–25% in the first 24 h. Grise and colleagues hypothesized that BP-lowering agents are commonly initiated in the emergency department (ED) for patients below recommended levels, and that BP reduction exceeds 20%. This retrospective study included 1739 patients from 16 hospitals in the Greater Cincinnati area with median age 72 years, 43% male, and 25% African American demographics. Patients receiving recombinant tissue-type plasminogen activator were excluded. Of the patients treated with antihypertensives (218/1739), the median National Institutes of Health Stroke Scale score was 4, compared to 3 for the group not treated (p = 0.028). In addition, more of these patients were African American (18.6% vs. 10.7% white, p < 0.001). Only 30% (65/218) met treatment criteria with regard to their BP level. An additional 40 cases (36.7%) met criteria for treatment but did not receive antihypertensives. Median change in systolic BP was a reduction in 12.3%, with 52 treated patients (23.7%) experiencing > 20% reduction. According to the results of this study, one-third of patients treated with antihypertensives for AIS did not actually meet AHA guidelines for treatment. Additionally, nearly 1 in 4 patients experienced overly aggressive BP lowering in the ED. A theorized reason for this was the treating physician's approach to AIS as a form of hypertensive emergency, thus erroneously striving to rapidly drop elevated BP levels.

The Effects of Sepsis on Mitochondria: Garrabou G, Moren C, Lopez S, et al. J Infect Dis 2012;205:392–400.

Maegan S. Reynolds — 2012-05-01

In this laboratory study, the authors attempted to analyze mitochondrial function in sepsis. Specifically, they analyzed blood from 19 patients admitted from March 2005 to November 2009 who had evidence of the systemic inflammatory response syndrome by clinical criteria without septic shock, and compared the findings with blood from 20 matched healthy controls. Additionally, skeletal muscle biopsies were obtained from 5 healthy patients undergoing hip surgery to obtain mitochondrial samples. The authors specifically looked at: 1) mitochondrial protein synthesis, 2) mitochondrial complex I oxygen consumption, 3) enzymatic activity of mitochondrial respiratory chain (MRC) complexes I, III, and IV, 4) mitochondrial content, 5) plasmatic mitochondrial dysfunction inducer analysis, 6) mitochondrial membrane potential and caspase 3 as markers for apoptosis, 7) plasma mitochondrial DNA content, 8) plasmatic cytokines, 9) nuclear factor kappa-light-chain enhancer of activated B cells (NFκB) content as marker of inflammation, cellular stress, and survival, and 10) plasmatic nitrate/nitrite and lipid peroxidation as markers for oxidative stress. The authors found that although in septic patients there was no change in the number or protein expression for mitochondria, there was a reduction of 32% in MRCI function, decrease of 42% in MRCIII activity, and 23% inhibition of MRCIV, indicating a decrease in oxidative capacity. Overall inflammatory markers increased in septic patients from 46% to 494%. Additionally, NFκB increased by 68% in septic patients, and nitric oxide increased by 174%, indicating increased inflammation and increased oxidative stress. There was also increased apoptosis in septic patients, indicated by an increase in depolarized mitochondria and levels of caspase 3. There was also a positive correlation between the levels of cytokines and the severity of sepsis, which also correlated with a worse outcome.

Association of Emergency Department Length of Stay with Safety-net Status: Fee C, Burstin H, Maselli JH, et al. JAMA 2012;307:476–82.

Lina Tran — 2012-05-01

This study investigated emergency department (ED) compliance with length-of-stay measures with respect to patient disposition and hospital safety-net status from data obtained from the 2008 National Hospital Ambulatory Medical Care Survey. Investigators included 24,719 adult ED visits in the study and divided them into non-safety-net EDs and safety-net EDs (defined by the Centers for Disease Control as EDs with more than 30% Medicaid or uninsured patients or combined uninsured or Medicaid patients of more than 40% of the patient pool). Non-safety-net and safety-net ED lengths of stay were compared, using median times and 90th percentile, depending on disposition: admission, discharge, transfer, and observation, and compliance with national proposed length-of-stay measures (8 h for admissions and 4 h for discharges, transfers, and observations) was determined. Researchers found no difference in median length of stay between safety-net EDs vs. non-safety-net EDs, listed as follows by disposition: for admissions, 269 min vs. 281 min; for discharges, 156 min vs. 148 min; for observations, 355 min vs. 298 min; and for transfers, 235 min vs. 239 min. Safety-net status was not found to be independently associated with compliance with ED length-of-stay measures for any disposition type; the odds ratio (OR) for admissions was 0.83 (95% confidence interval [CI] 0.52–1.34); 1.03 for discharges (95% CI 0.83–1.27); 1.05 for observations (95% CI 0.57–1.95); 1.30 for transfers (95% CI 0.70–2.45). The study included multivariable analyses on patient demographics, hospital type (ie, rural, urban), physician type (ie, resident, physician assistant, attending physician), and admission/discharge subcategory (critical care, psychiatric, routine), and found no association with safety-net status and compliance with length-of-stay measure except for psychiatric discharges; OR 1.67, 95% CI 1.02–2.74.

Long-term Cardiovascular Mortality after Procedure-related or Spontaneous Myocardial Infarction in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome: A Collaborative Analysis of Individual Patient Data from the FRISC II, ICTUS, and RITA-3 Trials (FIR) Damman P, Wallentin L, Fox K, et al. Circulation 2012;125:568–76.

Elena Ewert — 2012-05-01

Although procedural interventions are commonly performed in patients with acute coronary syndrome, there is a known complication of procedure-related myonecrosis that may occur from various insults sustained during percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The true incidence of procedure-related myocardial infarction (MI) depends on the sensitivity of myonecrosis markers, the upper limit of normal for these markers, and how these types of MI are defined in contrast to spontaneous MI. If the incidence of procedure-related MI is significant, and if the mortality of such types of MI are higher than the spontaneous form, then it stands to reason that appropriate preventative or therapeutic interventions would be essential for patients undergoing PCI or CABG. With this in mind, Damman et al. evaluated 5-year follow-up of long-term cardiovascular mortality from procedure-related and spontaneous MI in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), derived from a combined cohort from the Fast Revascularization During Instability in Coronary Artery Disease (FRISC-II) trial, Invasive vs. Conservative Treatment in Unstable Coronary Syndromes (ICTUS) trial, and Randomized Intervention Trial of Unstable Angina (RITA-3) – collectively referred to as the FIR population. Slight differences among these groups included post-procedural biomarker testing and definition of the upper limit of normal. Data analysis included Kaplan-Meier estimates of cumulative event rates as well as time-dependent Cox proportional hazards models to assess hazard ratios. Of 5467 patients, a total of 212 procedure-related MIs and 236 spontaneous MIs occurred within 6 months after enrollment. In patients with a procedure-related MI, cumulative cardiovascular death rate was 5.2% (11 of 212 patients), compared to 22% of those with a spontaneous MI (52 of 236 patients). Hazard ratios for those with procedure-related MI were comparable to those without procedure-related MI (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.36–1.20, p = 0.17, no significant difference with risk-factor adjustment). However, HRs were notably higher for those with spontaneous MI compared to those without (HR 4.52, 95% CI 3.37–6.06, p < 0.001; risk-factor adjusted HR 2.47, 95% CI 2.04–3.83, p < 0.001). There was no difference in occurrence of a procedure-related MI in revascularized patients. In conclusion, this study found that for the sample of patients with NSTE-ACS from the FIR population, no association between procedure-related MI and long-term cardiovascular mortality was found at 5 years, compared to a substantial increase in long-term mortality after a spontaneous MI within 6 months.

Patients with Acute Coronary Syndrome and Normal High-sensitivity Troponin: Meune C, Balmelli C, Twerenbold R, et al. Am J Med 2011;124:1151–7.

Maegan S. Reynolds — 2012-05-01

In this prospective multi-center cohort study, the authors sought to characterize the incidence of and outcomes for patients with acute coronary syndrome (ACS) but a normal high-sensitivity cardiac troponin (hs-cTNs) at presentation. The patients were all participants in the Advantageous Predictors of Acute Coronary Syndrome Evaluation (APACE) evaluated between April 2006 and May 2010, and were diagnosed with either acute myocardial infarction (AMI) or unstable angina (UA). In total, 1181 patients were in the initial cohort and were followed for 360 days for all-cause mortality or repeat AMI. A total of 351 patients (30%) were diagnosed with ACS, of whom 32% (112/351) had normal hs-cTN, 53% (187/351) were diagnosed with AMI, and 47% (164/351) were diagnosed with UA. Interestingly, 5.9% (11/187) of AMI patients had normal hs-cTN at presentation, although all had elevated troponins within 3 h. Most of the UA patients (61.6%) presented with normal troponin. Only 7 of these patients (11.4%) developed elevated hs-cTN on serial measurement in contrast to all of those with AMI. The authors found that younger age, previous statin treatment, normal renal function, and the absence of ischemic electrocardiogram changes were associated with a normal hs-cTN at presentation, indicating that assessment of troponins at the time of presentation may be limited in this population. During outcome analysis, the ACS patients' all-cause mortality was increased in those with elevated vs. normal hs-cTM at presentation (17.5% vs 2.0% at 360 days). Total all-cause mortality was similar between patients with non-cardiac chest pain (1.8%) and patients with ACS but normal troponin at presentation (2.0%) throughout 1-year follow-up.

Concurrent Use of Warfarin and Antibiotics and the Risk of Bleeding in Older Adults: Baillargeon J, Holmes HM, Lin Y, Raji MA, Sharma G, Kuo YF. Am J Med 2012;125:183–9.

Lina Tran — 2012-05-01

This was a case-control cohort study that investigated the risk of bleeding in older adults on chronic warfarin with concurrent use of any of six commonly prescribed antibiotic classes: azole antifungals, macrolides, quinolones, cotrimoxazole, penicillins, or cephalosporins. The study used data from the Medicare Part D prescription drug program to identify 38,762 adults aged > 65 years on chronic warfarin and followed them for a study period of 1 year (2008), and recorded cases of bleeding events requiring hospitalization and their association with antibiotic exposure, divided by recency of exposure as: 0–15 days, 16–60 days, or > 60 days. Each case identified was matched with three controls based on indication for warfarin use, age, sex, and race/ethnicity. The study identified 798 cases, and using logistic regression analysis the researchers found that chronic warfarin users exposed to any antibiotic agent were twice as likely to experience a bleeding event than those who were not exposed (adjusted odds ratio [aOR] 2.01; 95% confidence interval [CI] 1.62–2.50), where antibiotic exposure was most associated with non-gastrointestinal (GI) bleeding sites, aOR 2.49 (95% CI 1.88–3.30) vs. GI bleeding sites, aOR 1.68 (95% CI 1.28–2.21). Exposure within 0–15 days or 16–60 days showed similar associations with bleeding events compared to the referent group, aOR 2.37 (95% CI 1.75–3.22) and 2.11 (95% CI 1.50–2.97), respectively, whereas exposure > 60 days prior was not associated with bleeding events, aOR 1.25 (95% CI 0.78–2.01). All antibiotic classes were associated with increased bleeding, starting with azole antifungals, aOR 4.57 (95% CI 1.90–11.03), followed by (in decreasing order): cotrimoxazole, aOR 2.70 (95% CI 1.46–5.05); cephalosporins, aOR 2.45 (95% CI 1.52–3.95); penicillins, aOR 1.92 (95% CI 1.21–2.07); macrolides, aOR 1.86 (95% CI 1.08–3.21); and quinolones, aOR 1.69 (95% CI 1.09–2.62). The researchers also investigated concurrent use of other potentially confounding medications and found that selective serotonin-reuptake inhibitors and corticosteroids were associated with increased bleeding risks.

Diagnostic and Prognostic Stratification in the Emergency Department Using Urinary Biomarkers of Nephron Damage: A Multicenter Prospective Cohort Study: Nockolas T, Schmidt-Ott K, Canetta P, et al. J Am Coll Cardiol 2012;59:246–55.

Elena Ewert — 2012-05-01

Acute kidney injury (AKI) is both a common and a serious diagnosis made in over 1 million hospitalized patients each year in the United States. Although elevated serum creatinine and decreased urinary output currently define AKI, utilizing these in the emergency department (ED) can be challenging when baseline levels are not known and normal levels can mask intrinsic injury at the cellular level. To address this issue, several urinary biomarkers have recently been discovered to detect and measure intrinsic AKI (iAKI). Among these, the five most promising are urinary neutrophil gelatinase-associated lipocalin (uNGAL), urinary kidney injury molecule-1 (uKIM-1), urinary liver-type fatty acid-binding protein (uL-FABP), urinary interleukin-18 (uIL-18), and urinary cystatin C (uCysC). To determine if they successfully distinguish iAKI from prerenal AKI or chronic kidney disease, and to evaluate their collective diagnostic accuracy with regard to predicting adverse clinical outcomes, this prospective observational cohort study measured these biomarkers in 1635 heterogeneous ED patients from three different urban hospitals at the time of hospital admission. To be included, patients had to be > 18 years of age and admitted to the hospital, irrespective of diagnosis or ultimate length of stay. Exclusions included < 24 h of follow-up or chronic renal replacement therapy. Patients were assigned to one of five classifications: normal kidney function, stable chronic kidney disease, prerenal AKI, iAKI, and unclassified (not meeting criteria for any group). From the total population, 96 patients (5.8%) had iAKI, and 72 patients (4.4%) had the composite outcome of dialysis initiation or death. Primary etiologies for iAKI were hypotension (34%), urinary obstruction (29%), sepsis (22%), glomerulonephritis or vasculitis (6%), hepatorenal syndrome (2.1%), and rhabdomyolysis (2.1%). Other less common (1%) etiologies were contrast nephropathy, acute interstitial nephritis, scleroderma crisis, and multiple myeloma. Whereas all biomarkers were elevated, uNGAL showed highest sensitivity and specificity (68% and 81%, respectively, at 104-ng/mL cutoff) for predicting severity and duration of AKI. This compared to serum creatinine, where levels > 1.4 ng/mL are 81% sensitive and 82% specific for diagnosing AKI. Along with uKIM-1, uNGAL also predicted composite outcome of dialysis initiation or death during hospitalization (integrated discrimination improvement risk estimate 0.022, p <0.001 for uNGAL, and 0.017, p < 0.001 for uKIM-1 compared to serum creatinine alone). Importantly, this risk was also predicted among patients with normal serum creatinine levels (< 1.4) at hospital admission (227 patients [5.3%] classified as intermediate risk by uNGAL level and 264 patients [5.3%] intermediate risk by uKIM-1 level, p < 0.01). As this study showed, when combined with creatinine levels, and particularly when these levels are normal, the urinary biomarker uNGAL, and to a lesser extent uKIM-1, imparts prognostic value in assessing those at higher risk for mortality during hospital admission for patients with intrinsic AKI.

Calendar of Events

2012-05-01

Pulmonary Embolism Presenting as Flank Pain: A Case Series

Michael Amesquita, Michael N. Cocchi, Michael W. Donnino — 2009-03-31

Abstract: Background: Pulmonary embolism (PE) is a potentially fatal disease that can be effectively treated once diagnosed. Due to insidious and often cryptogenic presentations, the diagnosis of this disease can easily elude clinicians. Over the last several years the use of computed tomography (CT) scanning has improved the clinician's ability to diagnose PE. In addition, the widespread use of CT to investigate other complaints such as flank and abdominal pain could theoretically result in radiographic findings not previously identified that could point to the diagnosis of PE. The current case series reveals the unexpected and initially unrecognized CT finding of a pulmonary infarct in two patients presenting with flank pain; a third patient presented with flank pain and was also found to have a PE. Objective: We describe three cases of patients who presented to the Emergency Department with flank pain who were diagnosed with pulmonary embolism. Case Reports: The cases reported here discuss patients who presented with flank pain and were ultimately diagnosed with PE. In the first two cases, the patients had incidental findings of pulmonary infiltrates on abdominal CT scans, which prompted further diagnostic investigation. In the third case, the patient had risk factors for PE and presented with flank pain and the diagnosis was quickly made by CT imaging. Conclusion: Physicians should consider pulmonary embolism in the differential diagnosis of patients with isolated flank pain. Additionally, unexpected pulmonary findings on abdominal CT scans may help suggest the diagnosis of PE in the appropriate clinical setting.

Covert Cryptococcal Meningitis in a Patient With Systemic Lupus Erythematous

2009-05-14

Abstract: Background: Cryptococcal meningitis is a rare but well-recognized illness with a high mortality rate in immunosuppressed patients with systemic lupus erythematosus (SLE). The diagnosis of cryptococcal meningitis in these patients can be challenging, especially in the emergency department (ED), as the clinical presentation may be non-specific, which can lead to delayed treatment. Objective: To recognize risk factors associated with the development of cryptococcal meningitis infection in patients with SLE and to provide an update on the clinical presentation, prognosis, and therapeutic options. Case Report: A 21-year-old man with SLE presented with a 4-day history of headache, fever, nausea, and vomiting after being discharged from the ED 1 day before this visit, after lumbar puncture showed normal values. One week before, he had completed 7-day pulse therapy with intravenous cyclophosphamide and intravenous methylprednisone for lupus nephritis. The patient was febrile, but the remainder of the examination was normal. Laboratory data showed lymphopenia. Given his immunocompromised state, a cryptococcal antigen was added to cerebrospinal fluid (CSF) sent from the prior ED visit and was positive at a titer of 1:8. The patient was treated with amphotericin B and 5-flucytosine for 6 weeks. Ten months later the patient remained free of infection. Conclusion: Normal neurological and CSF examination do not exclude cryptococcal meningitis in immunocompromised patients with SLE. India ink or, preferably, latex agglutination test and CSF fungal culture are recommended. A high level of suspicion is the key in the diagnosis of cryptococcal meningitis and will help avoid delays in treatment.

Chronic Aortic Dissection in a Young Adult

Adam B. Landman, Sam S. Torbati — 2009-05-14

Abstract: Background: Acute aortic dissection is a life-threatening disease that is often a diagnostic challenge in the Emergency Department (ED). Patients with acute aortic dissection often have underlying hypertension and atherosclerotic disease, and commonly present with acute-onset severe chest or back pain in their sixth or seventh decades of life. Aortic dissection, however, can also be seen in patients < 40 years old and may present chronically, with symptom duration longer than 2 weeks. Objective: We present an unusual case of chronic aortic dissection in a young patient, followed by a review of the literature on chronic aortic dissections and aortic dissections in young patients. Case Report: We report a case of chronic aortic dissection in a 32-year-old man with a history of untreated hypertension who presented to the ED with palpitations and mild shortness of breath. Conclusion: Acute and chronic thoracic aortic dissections can occur in patients of all ages, as well as in patients with atypical signs and symptoms.

Pseudo Subarachnoid Hemorrhage in Meningeal Leukemia

Sun-Wung Hsieh, Gim-Thean Khor, Chau-Nee Chen, Poyin Huang — 2010-05-10

The characteristic finding of subarachnoid hemorrhage (SAH) is the increased attenuation in the basal cisterns and subarachnoid spaces on brain computed tomography (CT) scan. The appearance of SAH in imaging without true subarachnoid blood has become known as pseudo-SAH and it often leads to misdiagnosis initially. Here we report a case of pseudo-SAH in a patient with meningeal leukemia.

Traumatic Hemobilia Without Liver Parenchymal Injury Due to Blunt Trauma

Oh Young Kwon, Jong Seok Lee, Han Sung Choi, Hoon Pyo Hong, Young Gwan Ko — 2010-05-26

A 47-year-old previously healthy man presented to the Emergency Department (ED) with epigastric pain. The patient had been kicked several times in his abdomen approximately 20 h before presenting to the ED. His vital signs included a temperature of 36.2°C, respiratory rate of 20 breaths/min, pulse rate of 76 beats/min, and a blood pressure of 160/90 mm Hg. The physical examination found diffuse tenderness over the epigastric and right upper quadrant of the abdomen, but no rebound tenderness or external wounds were observed. Laboratory studies revealed a hemoglobin level of 13.0 g/dL, hematocrit 36.4%, total bilirubin 2.9 mg/dL, aspartate aminotransferase 1049 units/L, and alanine aminotransferase 516 units/L. Urinalysis revealed more than 30 red blood cells per high power field. Bedside ultrasonography and standard radiographs were performed, but no abnormal findings were reported. An abdominal computed tomography (CT) scan was requested to investigate the possibility of liver or kidney injury and demonstrated high-attenuation lesions (40–50 Hounsfield units [HU]) in the gallbladder and common bile duct (CBD), and mild dilatation in the distal CBD (). The patient had no hemoperitoneum or internal organ injury. He was diagnosed primarily as having an incidental distal CBD stone because the high-attenuation material may have been inspissated bile due to an impacted radiolucent stone in the CBD. Three hours after the CT scan, he complained of more severe abdominal pain and vomited approximately 200 mL of bright red blood. The patient then underwent emergency gastrointestinal endoscopy, which showed scanty blood at the ampulla of Vater. An endoscopic retrograde cholangiopancreatography (ERCP) procedure was performed in the endoscopy suite for evacuation of the hematoma in common bile duct. Blood clots and a large volume of fresh blood were extracted, and a nasobiliary catheter was placed for further reduction of biliary pressure. The patient was confirmed as having traumatic hemobilia. On hospital day 4, the patient no longer complained of abdominal pain, and he was discharged in stable condition on hospital day 15.

Dysrhythmiartifact

Sony Jacob, Joya A. Ganguly, Naga V.A. Kommuri — 2010-06-25

A 68-year-old woman with a medical history significant for dyslipidemia and diabetes mellitus presented to the Emergency Department with pre-syncope. On arrival, she was found to be mildly hypertensive, but otherwise stable. Her physical examination was within normal limits, and her chest X-ray study was unremarkable. A 12-lead electrocardiogram (ECG), obtained on a General Electric/Marquette MAC 5000 was suspicious for a dysrhythmia (A, ). It appeared to be atrial in nature, with the resemblance of electrical deflections similar to “pacemaker spikes” with a cycle length of 50 ms. All leads were involved, but the amplitude of these “pacemaker-like spikes” was more in the inferior and inferolateral leads, and minimal in leads 1 and V1. The stability of the amplitude of the artifacts in the limb leads suggested that the source of the artifact had to have a fixed position and inferior orientation relative to the patient's body. On further discussion, it was discovered that the patient had a history of neurogenic bladder, for which a spinal neurostimulator (InterStim®; Medtronic, Minneapolis, MN) was implanted subcutaneously on the lower back for bladder control. The device was deactivated later and the artifact disappeared (B).

Magnetic Resonance Imaging of Cerebral Malaria

2010-08-13

A 37-year-old man presented with moderate to high-grade fever for 10 days and altered sensorium for 2 days. Physical examination revealed jaundice and hepatosplenomegaly. On neurological examination, he was in a confused state and was not oriented to person, place, or time. A motor examination showed increased tone in all four limbs, and bilateral plantar reflexes were extensor. Sensory and cerebellar systems were grossly normal. Laboratory investigations for typhoid, leptospirosis, and dengue fever were negative. A Quick Diagnostic kit (QDx) test was positive for Plasmodium falciparum. QDx is a rapid card test to diagnose malarial infection, and has sensitivity similar to or slightly lower than that of thick film for plasmodium. Thus, the diagnosis of cerebral malaria was made. Magnetic resonance imaging (MRI) showed lesions in the corpus callosum, bilateral in thalamic and cerebellar hemispheres (). There was no evidence of restricted diffusion on diffusion-weighted imaging. The patient was treated with antimalarials and emergency supportive care. A follow-up MRI study performed 4 months later showed near complete resolution of the brain lesions ().

Posterior Sternoclavicular Joint Dislocation with First Rib Fracture and Ipsilateral Vocal Cord Palsy

Mehmet Sukru Sahin, Tarkan Ergun, Gokhan Cakmak, Mehmet Akyuz — 2010-09-30

A 38-year-old man who was ejected from his car during a traffic accident was brought to our Emergency Department (ED). He had complaints of right shoulder and upper chest pain when moving his shoulder. On admission he was conscious but did not respond to questions. The physical examination revealed very limited and painful movement of the right shoulder, tenderness, and swelling of the right sternoclavicular joint, and difficulty speaking. Bony swelling appeared slightly superior to the contralateral sternoclavicular joint. Posterior displacement of the medial end of the clavicle was observed. Plain film of the chest and clavicles revealed only slight asymmetry between the clavicles but no clear evidence of dislocation (). Computed tomography (CT) scan (A) and three-dimensional CT scan (B) revealed retrosternal dislocation of the right sternoclavicular joint, retrosternal hematoma, fracture-dislocation of the first rib with thickening, medial positioning of the right aryepiglottic fold, and anterior positioning of the right arytenoid cartilage consistent with vocal cord palsy ().

Editorial Board

2012-05-01

Issue Highlights

2012-05-01

Partial Contents of Volume 42, Number 6

2012-05-01